11.25.2009

How Lean Principles Apply to End-of-Life Medical Care

A thoughtful segment on 60 Minutes recently explored the thorny issues surrounding the costs of caring for people at the end of their lives. It struck me that some of those issues relate to lean principles.

The story, reported by Steve Kroft, noted that last year, Medicare paid $50 billion just for doctor and hospital bills during the last two months of patients' lives – and it has been estimated that 20 to 30 percent of those medical expenditures may have had no meaningful impact.

I was particularly struck by comments from Dr. Ira Byock of Dartmouth-Hitchcock Medical Center in Lebanon, N.H., who leads a team that treats and counsels patients with advanced illnesses.


By law, Medicare cannot reject any treatment based upon cost. It will pay $55,000 for patients with advanced breast cancer to receive the chemotherapy drug Avastin, even though it extends life only an average of a month and a half; it will pay $40,000 for a 93-year-old man with terminal cancer to get a surgically implanted defibrillator if he happens to have heart problems too.
"I think you cannot make these decisions on a case-by-case basis," Byock said. "It would be much easier for us to say 'We simply do not put defibrillators into people in this condition.' Meaning your age, your functional status, the ability to make full benefit of the defibrillator. Now that's going to outrage a lot of people."


In lean operations, we argue in favor of standard work – doing something the same way every time. What Byock is arguing for is not exactly the same thing, but the principle is similar.

And before you argue that not all patients are the same – which is true – consider the words of David Walker, former head of the Government Accountability Office and how head of the Peter G. Peterson Foundation. He commented in the story that this is not just about medical care, but what government pays for medical care.


“Let me be clear: Individuals and employers ought to be able to spend as much money as they want to have things done. But when you're talking about taxpayer resources, there's a limit as to how much resources we have."


One other lean concept I’d like to mention is that there must be complete information about what is happening in order to choose the best course of action. In lean terms, that typically means choosing the right improvement, and measuring its results. I mention the concept here in a slightly different way, in terms of choosing the most appropriate course of action based on a full understanding of the likely impact of that action.

The 60 Minutes report noted that studies have shown most dying patients and their families would prefer the last days be spent at home (though most end up dying in hospitals). But to make a choice, patients and their families must understand the situation – which is often not the case, according to another person interviewed for the segment, Dr. Elliott Fisher, a researcher at the Dartmouth Institute for Health Policy.


"At some point, most doctors know that a patient's not likely to get better," Kroft remarked.
"Absolutely," Fisher agreed. "Sometimes there's a good conversation. Often there's not. You know, patients are left alone to sort of figure it out themselves."


I was once involved in a difficult, end-of-life decision. The fact that the doctors involved were clear and honest about the situation was important and helpful.

Dealing with these kinds of issues is one of the toughest aspects of improving healthcare. Perhaps lean principles can help.

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